July 1, 2024 • 52 mins
Join us on The Gut Health Podcast as we uncover the many facets about constipation with the distinguished gastroenterologist, Dr. Darren Brenner. Think probiotics are the cure for your sluggish digestive system? Think again. Dr. Brenner dispels common myths and reassures us about the safety of stimulant laxatives like Senna and Bisacodyl when used correctly. Together, we'll redefine what it means to be constipated, acknowledging that not everyone needs the "perfectly formed" daily bowel movement to be healthy.
Dive into the often-missed topic of pelvic floor dysfunction and how it contributes to constipation. Dr. Brenner breaks down the complexities of functional defecation disorders and dyssynergic defecation, emphasizing the urgent need for early diagnosis and the role of specialized physical therapy. The conversation doesn't shy away from discussing the significant impact of trauma on pelvic floor health, advocating for open, empathetic communication between patients and providers to create a supportive therapeutic environment.
For those over 45, we highlight red flags in constipation that you shouldn't ignore, from unexplained weight loss to sudden changes in bowel habits. Learn the distinctions between Small Intestinal Bacterial Overgrowth (SIBO) and Intestinal Methanogenic Overgrowth (IMO) and how they can exacerbate your symptoms. Finally, take home practical tips on nutrition, stress management, proper toileting behavior, and the importance of regular exercise. Dr. Brenner even shares his expert strategies to help you maintain great elimination habits, a healthy gut and overall well-being.
Check out some great constipation references/resources below:
Kate Scarlata's e-book, Constipation Essential: Your Guide to a Better Exit Strategy (this is a 20-page comprehensive guide about constipation types and treatments.)
The psyllium powder Kate uses is Kate Naturals (not Kate Farms), here is an Amazon link to the product.
Brenner, D et al. Best Practice for the Management of Chronic Idiopathic Constipation and Irritable Bowel Syndrome with Constipation: A Roundtable Discussion and Review. The American Journal of Gastroenterology 117(4S):p S1, April 2022
IBS-C: New & Novel Management: Webinar via Tuesday Night IBS
A multi-disciplinary approach to IBS with constipation.
Axis, A et al Gastroenterology and Endoscopy News, 2024. Emerging Treatments for Chroni
Learn more about Kate and Dr. Riehl:
Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast
Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.
The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kate Scarlata (00:00):
This podcast has been sponsored by Ardelyx.
Maintaining a healthy gut iskey for overall physical and
mental well-being.
Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
issues, or a healthcare provider, you are in the right place.
(00:22):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Dr. Megan Riehl (00:37):
Hello friends, and welcome to the Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Megan Riehl, a GIpsychologist.
Kate Scarlata (00:50):
Hi, I'm Kate Scarlata.
We have an exciting podcast foryou.
Today, w e are talking allabout constipation, a condition
that impacts up to one in fiveAmericans.
A recent survey study showedthat three out of five people
living with constipation neverdiscuss their symptoms with a
(01:10):
healthcare provider, and we arehere to change that, because
there's many new and noveltherapies for constipation,
including taking vibratingcapsules that can help improve
your exit strategy.
Dr. Megan Riehl (01:25):
So our guest today is a professor of medicine
at Northwestern University andhas Wolverine roots, go blue,
and I've had the privilege ofworking with him very early in
my career.
Dr.
Darren Brenner is a belovedgastroenterologist to his
patients and has a trueunderstanding for the
(01:46):
complexities of living life withGI disorders.
Not only does he travel theworld lecturing on disorders of
gut-brain interaction, like IBS,which we talk about a lot and
more, he is a researcher and anexpert in GI motility and pelvic
floor disorders.
We are thrilled to have himwith us today and we have no
doubt that everyone listeningwill be entertained while we
(02:06):
explore this topic of notpooping or constipation.
So welcome, Dr.
Brenner.
Darren Brenner, MD (02:13):
Thanks Megan , thanks Kate.
Yeah, it's amazing what I dofor a living, isn't it?
Dr. Megan Riehl (02:16):
Yeah, who would have thought, you know?
But we love it.
Kate Scarlata (02:19):
We do love it.
All about poop.
So, in the world of gut health,we really like to break through
the misconceptions and mythsout there because, as you know,
tiktok is full of them.
So we would love to have yourexpertise here.
Can you myth bust for us what'ssomething you'd like to dispel
with our audience?
Darren Brenner, MD (02:40):
Yeah, so I think this is something I see
all the time.
This is something patients comeback with questions and
physicians alike, and it'sreally some myths and
misconceptions on things thatwork and don't work and can be
safe or unsafe for treatingconstipation.
And this is a multi-billiondollar industry with almost
little to no regulation,especially in the
(03:06):
gastrointestinal space.
If somebody goes to the storeand wants to look for a
probiotic, the packages saypromotes gut health or promotes
gut immunity, but really can'tmake any claims about this
particular illness.
And there have been some recentstudies that showed up to a
quarter of individuals withconstipation are trying to treat
(03:26):
their symptoms with probiotics,in many cases probiotics alone,
and, I'm sad to say, at leastin 2024, there really isn't a
lot of evidence or data tosupport that.
So I guess that's mylong-winded way of saying if you
think probiotics are going tofix your constipation, it's very
unlikely.
Now, on the flip side is thetaboo, and this has been around
(03:46):
for 40, 50 years.
There've been lots of papers.
We're still writing myths andmisconceptions about the use of
stimulant laxatives, things likeSenna or Bisacodyl.
We've been told that they'llcause cathartic colon or dead
colons or atonic colons or longcolons or melanosis coli or
colon cancer, and the list goeson and on and on.
But the reality of thesituation is that in standard
(04:10):
doses, these therapeutics arevery safe and very effective.
So if you're a patient who aretaking standard doses of Senna
or Bisacodyl, I don't want themto worry that anything is going
to happen to their GI tracts orthat these are, in any way or
shape, harmful for them in thelong term.
Kate Scarlata (04:27):
I am so, so glad you said that, because I get
that question all the time andeven when I'm amongst other
gastroenterologists, I feel likesome of them believe that
there's a problem there, but theexpert here is saying, no,
don't worry about that.
And I think that is a reallyimportant message for people out
(04:47):
there who find that Sennareally works for them, and then
someone tells them dial it back,you can't be on that.
So thank you for that.
That's huge.
Dr. Megan Riehl (04:57):
It really highlights the individuality of
everyone's gut and that yourtoolbox is going to look
different from the next person,from the next person, from the
next person.
Darren Brenner, MD (05:08):
Absolutely.
I mean, I think that's thebeauty of what we do.
You know, people are asking foralgorithms.
We try to put these algorithmstogether, but, megan, to your
point, everybody is anindividual unto himself or
herself, and so the treatmentshave to be different.
I think that's what makesmedicine, especially treating
disorders of gut braininteraction, so fascinating.
Kate Scarlata (05:25):
That's right, I agree.
So let's just dial it back withconstipation.
Can you define constipation forthe lay audience?
Because I have patientssometimes that say, oh, I didn't
poop in the last 12 hours, so Ihave constipation.
Or if they skip a day ofpooping, they have constipation,
but that's not true.
(05:45):
Day of pooping, they haveconstipation, but that's not
true, right?
Darren Brenner, MD (05:47):
That's right and it's just like we mentioned
.
It's different for everybodyand I mean that from a
practitioner and a patientstandpoint.
Unfortunately, to ourconversation earlier about
TikTok, the lay person has beentaught that they have to have
one perfect what looks like asausage ball movement every day,
and that's just not reality andI think that's actually more
(06:08):
the exception than the norm.
And so when we think aboutconstipation, at least
historically, we break it into alot of different symptoms,
because it's different strokesfor different folks and
absolutely frequency does play arole here, but normal.
We have found, initially inEurope and more recently in the
United States, that about 95% ofthe US population has a bowel
(06:30):
movement anywhere between threetimes a day to three times a
week.
Now that sounds extreme, thatnorms can be three to 21 bowel
movements a day, but that is thereality of the healthy average
individual in the United States.
We talk about texture.
I think those of us in academiause the Bristol stool form
scale.
I think a lot of people andpatients who focused on their
(06:52):
bowels know what this scale is,but I don't think the average
individual does, and it's ascale that defines stool based
on its texture and not to grossanybody out during this podcast,
but we really defineconstipation as things that look
like milk duds or baby roofbars, and I've been using that
analogy probably for two decadesnow, but it's because it really
(07:14):
hits home.
I think people can relate towhat those types of stools look
like.
We talk about subjectivesymptoms.
Do you strain to go to thebathroom?
Do you not feel like you geteverything out when you go,
which I think is one of thehardest things to overcome?
Do you feel obstructed?
Do you feel a heaviness or apressure in your pelvic floor?
You feel like you have to go tothe bathroom and you just can't
(07:35):
get it out.
And then the taboo that nobodywants to talk about do you need
to perform manual maneuvers andI hope nobody's watching this
during breakfast, lunch ordinner because I'm going to
describe these but we talk aboutmanual disimpaction having to
stick a finger into your bottomand try to rake or pull the
stool out.
Or, for women, we talk aboutsplinting having to take a
(07:56):
finger or two and put them inthe vaginal cavity and push
posteriorly, which reduces allkinds of anatomical variance
that can obstruct the stool fromcoming out.
And again, some people willcome in with all of these, some
one or two of these, and so itis a different I would say du
jour for everybody.
When we meet these patients, Ialways like to talk about a
specific type of constipation,because I do see these
(08:19):
individuals regularly and Ithink they suffer for a long
time and these are the peoplethat are defined with diarrhea,
because they come in and theirchief complaint is I have 10, 15
bowel moments a day.
When you start to tease outthese other symptoms, they say I
have 10 hard pellets or I'mstraining, or I feel incomplete
evacuation, and what they'rereally having in many instances
(08:40):
is constipation with overflow.
There are hard impacted stoolsat the bottom of the GI tract.
The stuff above it gets looserand it finds a way to leak
around it, and unfortunately,these people are treated with
anti-diarrheals, which justmakes the process worse.
And so in many instances, whensomebody comes in and we're not
sure if they have constipationor diarrhea, I think your best
(09:03):
friend can be an abdominal x-ray, because you'd be surprised how
many times you will find thatthere's just a significant
amount of stool in the colon,which will identify specifically
that this is more constipationthan diarrhea.
Kate Scarlata (09:15):
That's awesome.
And when they go in for anx-ray, is it a KUB x-ray?
What would they ask for withtheir physician?
Darren Brenner, MD (09:23):
It's a KUB and I think that can do a couple
of things.
I think we see as an overlap,where people are constipated, a
lot of abdominal complaints likeabdominal bloating and
distension.
These are two very differentthings and I think you can
really differentiate betweenthem with that KUB, because not
only do we see the stool contentof the colon but the gas
content.
(09:44):
So many times my patients comein and they say, as the day goes
on, I look six, nine monthspregnant, I'm full of gas.
We shoot the film and I canbring them back to the office
and say look, here's yourabdominal x-ray, here's what the
stool looks like, but there'sno excess gas, which sends us in
a completely differentdirection.
Kate Scarlata (10:00):
That's awesome.
I'm glad you do that because,again, I think not everyone
wants to do those x-rays and Iusually am in favor of them
because most of my patientsactually have constipation, so
it's kind of interesting.
So there's different types ofsubtypes of constipation.
You know IBS-C or chronicidiopathic constipation, slow
(10:20):
transit what's all this "garb?
Darren Brenner, MD (10:28):
Sure, let's talk about the hodgepodge and
how much I can confuse you whenit comes to constipation.
And I will preface that bysaying that when we're in
medical school or, I think,dietary school or psychology
school, what we're always taughtis this If you're not sure
what's going on, take morehistory.
And if you're still not surewhat's going on, take more
history.
And if you're still not surewhat's going on, take more
history.
(10:48):
And now I get to go back to allof my professors 20 years ago
and say, when it comes toconstipation, that may not
necessarily be true Becauseunfortunately, what we have
learned and what the clinicaltrial shows is this You're not
going to be able todifferentiate one person's
constipation from another basedon their subjective symptoms.
But it is important to try andfigure out what types of
(11:11):
constipation are underlying thepatient's symptoms, because I
think the biggest fallacy isthat somebody focuses on one
subtype.
They say aha, I think you haveirritable bowel syndrome with
constipation, and they focusright there.
And when I think ofconstipation, I really define it
along a Venn diagram, becausethere's a lot of overlap,
especially at the academiccenters.
So if you ask me whatconstipation is, I'll tell you
(11:34):
it's an overlap of fourdifferent subtypes.
And I start with the secondarycauses of constipation.
And yes, these are things thatwe can glean from a history and
a physical exam.
So, do you have a risk factorfor obstruction?
Are you of colon cancerscreening age?
Could this be, unfortunately, amass or some sort of
obstructive physiology?
Could it be related to anendocrinopathy?
(11:56):
Do you have diabetes,hypothyroidism?
Could it be a medication?
We talk about opioids andbenzodiazepines, but in reality
there are much more commontherapeutics out there,
especially in the cardiovascularclass beta blockers, thiazides,
ace inhibitors.
And then we need to realizethat older literature shows that
if an individual is on six ormore medications at any given
(12:19):
time, that threshold of sixincreases the odds ratio that
somebody will developconstipation.
In my world, where I see aneuromyopathic disorder,
scleroderma, parkinson's is ahuge one MS, als, these are all
things we can think about ascauses, but I want to caution
your listeners if you can defineone of those, don't stop there,
(12:40):
because then we want to thinkabout the three other categories
.
Kate, you mentioned oneirritable bowel syndrome with
constipation, and I call thisone the trap.
Okay, this is something thatmost young individuals come in
they complain about constipation, a little bit of bloating.
We snap our fingers, we say youhave IBSC, let's treat that.
And then 40 to 50 years laterthey come into our offices and
(13:01):
we say it could be somethingelse, like slow transit,
constipation the best name inhistory because it defines
constipation because things aremoving too slowly through the GI
tract.
And then obstructive physiology,what we call evacuation or
functional defecation disorders,which can be anatomical
problems rectus seals, enterusseals, intussusception which can
(13:24):
anatomically block the stoolfrom coming out.
And then the most common one wetalk about, which is
dyssynergic defecation, orpelvic floor spasm, or a nismis
where the muscles in the pelvicfloor do not work and so when
you try to go to the bathroom,instead of those muscles opening
up to allow stool to comethrough, then they open a little
bit, not at all, or go intospasm and impede the ability of
(13:44):
stool to come through.
Then they open a little bit,not at all, or go into spasm and
impede the ability of stool tocome out.
And it's very important earlyin the course to define this
disorder, because this is thedisorder that will not respond
to therapeutics like laxatives,and I think we're going to come
back to this a little bit later.
Dr. Megan Riehl (13:59):
And it won't respond to some of our
behavioral strategies.
It really requires, then,bringing on that pelvic floor
physical therapist.
And so you make such a hugepoint here that especially we
see this constipation moreprevalently with women.
And so if they're told you haveconstipation and then they're
(14:21):
not consulted by a pelvic floorphysical therapist or their
gastroenterologist hasn't done aphysical exam or some of the
additional workups that areavailable, like diphagraphy or
anal rectal manometry, thesepatients are going to suffer
more for longer and that's adisservice.
Darren Brenner, MD (14:39):
And that's part of our concern as
practitioners.
Our algorithm hasn't changed in20, 30 years and when we talk
about diagnostic testing, theaverage individual will probably
get a colonoscopy, but thefirst test recommended is
anorectal manometry and blueexpulsion testing.
Realistically, the first testrecommended is a digital rectal
exam, but I think we do a verypoor job training our trainees
(15:02):
on how to do that.
I always say the digital rectalexam is only as good as the
finger that's performing it andthus, if you're not comfortable
doing that exam, we really don'twant you invasive.
We can use the anorectalmanometry to better define
anorectal physiology.
And, Megan, you opened thatdoor talking about the pelvic
floor and I will walk throughthis door anytime I've given the
opportunity.
(15:22):
So please allow me to tangent alittle bit, because I always say
in my lectures and I always saywhen we're talking about these
types of things, I want to talkabout something that's near and
dear to your heart and that is ahistory of trauma, whether it
be physical, sexual or emotionaltrauma or abuse.
Because the reality is, the vastmajority of practitioners do
(15:44):
not ask about this, and thisplays a fundamental and key role
in constipation, because thereality of the situation is this
.
If your patient has a historyof physical, sexual, emotional
abuse or has undergone or gonethrough some form of trauma and
they have constipation, thepretest probability that their
pelvic floor doesn't work, basedon clinical literature and
(16:07):
anecdotal experience, is higherthan 90%.
And while with pelvic floorproblems we recommend the
physical therapy, the reality ofthe situation is, if we do not
mind pardon the pun thatbrain-gut connection, these
patients with physical therapyhave little likelihood of
success for improving theirconstipation symptoms.
(16:28):
So I beg all of your listeners,I beg all of my colleagues
around the world when you see apatient with constipation, ask
about this, because you willhave to target and focus on that
brain-gut interactionassociated with the trauma as
well.
Dr. Megan Riehl (16:41):
That's such an important point and, to your
point, sometimes we're notcomfortable doing the rectal
exam, and then there's an evenhigher prevalence that are not
comfortable to have thatconversation, and so I also beg
of you, as a listener, toadvocate for yourself to let
(17:02):
your physician know if you dohave a history of trauma, and
even if your provider hasn'tnecessarily asked about it, they
likely will be very able andcapable of making your
experience with either yourmedical procedures or subsequent
questions more comfortable.
So it's a two-way street.
(17:22):
You know we want peopleadvocating for themselves, but
it's such a good point thatphysicians, especially in this
area, and primary care doctorsand NPs and APPs, we do have to
be very mindful of thatconnection between our brain and
our gut and our lifeexperiences.
Darren Brenner, MD (17:41):
And please do advocate for yourselves.
I ask all of my patients, as amatter of fact, if they have a
history of trauma, I let themsee the manometry catheters,
feel them, touch them, know theexperience, walk through the
process, because in many casesthese individuals are not
comfortable undergoing theprocedure and they're not going
to be comfortable undergoingpelvic floor physical therapy.
(18:02):
It is a very invasiveintervention and they have to be
aware of what's going to happenwithin that clinical practice
and in many cases and I thankyou and all of your colleagues
for this brain, gut, behavioraltherapists get involved and we
start there and then we gobackwards to the diagnostic
testing and the treatmentassociated with pelvic floor
dysfunction.
Dr. Megan Riehl (18:21):
And even if you're somebody that doesn't
have a history of trauma andyou're feeling a little bit
anxious about a doctor that says, okay, I'm going to do a rectal
exam now, or you know it's timefor a colonoscopy, you're not
alone in feeling anxious aboutthis, and we, even in our book
Mind your Gut, we put in acolonoscopy coping kit to
highlight, you know that youcould ask for certain music, you
(18:44):
can do some breathing exercises, you can ask as many questions
as you want to yourgastroenterologist prior to any
of these procedures and you'llfeel more comfortable.
So those with a trauma history,and certainly the many that do
not have a trauma history, wewant you to be comfortable.
Your relationship with yourgastroenterologist is as about
(19:04):
as close as you can be, and soyou want to have a really good
therapeutic dynamic across thespectrum of your time working
together.
Kate Scarlata (19:14):
I love that and I would say, you know, I love
that you show or go through thetesting with your patients,
because I'd certainly hadpatients just arrive at the
testing and like what are wedoing here?
So I think if you're a listeneras a patient or you're a
listener as a provider, it isimportant that you ask what the
(19:35):
test entails and, as a provider,I always prep my patients like
this is the test, this is whatthey're going to be looking for.
It's important part ofunderstanding your pelvic floor,
but expect the following sothat they can decide you know,
or at least be prepped and notsurprised.
So one other question I wantedto talk about you have an
(19:59):
individual with constipation.
What are some other red flagsthat would really prompt you to
say we need to do furtherinvestigations here?
Something else is going onbeyond just constipation.
Darren Brenner, MD (20:12):
Yeah, great question, Kate.
I think, first and foremost, ifyou're over the age of 45,
request that colonoscopy.
I can pretty much assure thegastroenterologist is going to
want to do that.
That is the new screening ageand we're going to want to take
a look to make sure there'snothing obstructive.
Now that does not and I stressthe term not mean that if you
(20:32):
come in with new onsetconstipation over the age of 45,
that it is due to colon cancer.
I have found that very, veryinfrequently in my career.
As a matter of fact, havingprobably seen 20,000 people with
constipation, I can find thenumber of colon cancers that I
have identified on less than twohands.
Okay, so I don't want you toworry.
But that would be the firstthing.
(20:53):
Let us know if there has beenrecurrent or an increase or
crescendo in bleeding, if thisis an acute change, if there's
unexplained or unintentionalweight loss.
These are big triggers that wewant to know about.
These are things that mayindicate something else may be
going on.
But think about lifestylefactors as well.
(21:13):
Have you changed your diet?
If you change your diet, youshift your microbiome.
If you shift your microbiome,it may change the motility,
secretory and sensory patternsof your GI tract?
Or have you tried a newmedication?
Like I said, we talk about thebig ones, but there are hundreds
of medications out there thatcan cause constipation.
(21:33):
So let us know, and let us knowif something has changed,
because we may be able tocorrelate that specific change
with your new onset symptoms andallay your fears very quickly.
Dr. Megan Riehl (21:48):
All right.
So those are those red flags,and our listeners are going to
get really good at understandingwhat those are.
Again, we don't want you tohave a ton of anxiety.
If you do have a red flag, itjust is a good indicator that,
hey, you need to check in with adoctor and we'll go from there.
It doesn't have to mean thatthere's a cancer, and that
certainly is something that alot of people stress about,
which leads me to a segue hereto the brain-gut connection.
(22:09):
So you've mentioned thisconstipation can be a disorder
of gut-brain interaction.
So tell us a little bit fromyour gastroenterologist brain
and perspective how does thebrain-gut connection impact
constipation, and tell us alittle bit about what stress
does to that.
Darren Brenner, MD (22:28):
Yeah.
So you know, when I think aboutthe brain-gut connection, I
think about stress as it relatesto constipation.
I really take it out of thewhat's called slow transit
constipation component,irritable bowel syndrome.
We all know that stressexacerbates those symptoms and I
worry about my stress patientwhen it comes more so to the
(22:48):
disorders of the pelvic floor,and then I get into what I call
the sick cycle.
Pardon the pun again, but Ithink we as practitioners for
many years have poo-pooedconstipation as a nuisance
disorder and if you really takecare of these individuals, you
see it's much more than that.
It significantly impactsquality of life.
(23:08):
I can't get out of my house, Ican't leave the porcelain throne
.
I spend six, seven, eight hoursa day on that toilet and when
I'm not on the toilet, on thecouch perseverating about said
toilet because I feel likethere's still stool in there.
I'm afraid to go somewhere.
What if I get the urge?
What if I'm out to dinner withmy friends and I'm in the
bathroom for 30 minutes?
Is somebody going to comechecking on me because I think I
(23:30):
fell in the toilet or somebodyflushed me down the drain?
These are things that,realistically, I have heard over
and over again.
And the problem is when youstart to feel the stress and you
start to lose the quality oflife from those types of
symptoms that can increase whatwe see in the pelvic floor Spasm
of the muscles or an inabilityto relax because the brain talks
(23:52):
to the pelvic floor.
You have to coordinate thesetwo.
Just as much as I'm moving myhands right now, these are
skeletal muscles.
I'm coordinating them in avoluntary but very involuntary
manner.
I'm not thinking about it.
I have no idea what musclesthese are anymore.
I forgot that a long time agofrom basic anatomy.
But the muscles that I'mwiggling in front of all of you
right now are identical to themuscles in my pelvic floor the
(24:15):
puberectalis and external analsphincter that I learned when I
was potty training to open, upand close, and these muscles, if
I have these types of stressors, may not want to open anymore
and that leads to an increasedburden of stress, which leads to
more tightening of the pelvicfloor muscles, which leads to
increasing stress you can seewhere I'm going with this and
(24:35):
becomes a cycle and I call itbreak the cycle.
But here's where Kate comes intoour pyramid here, which is when
you have all that constipationand you feel horrible, you don't
want to eat and you may developsymptoms like our federal.
Eat less and so, because youeat less, you lose weight and as
you lose weight your GI tractslows down and you lose motility
(24:58):
, which means when you eat youfeel even worse.
So you eat even less and thenyou lose even more weight and
then you get to worse.
So you eat even less and thenyou lose even more weight and
then you get to a point whereyou don't have enough muscle
mass to impact or to work themuscles in the pelvic floor.
I see lots of patients who comein and they say I know my
problem is my pelvic floor andI've been to physical therapy,
but my physical therapist can'tfix this.
(25:19):
And I'll tell you in myacademic program if your BMI is
less than 16, my physicaltherapist won't touch you
because there's not enoughmuscle down there to fix.
So this becomes a cyclicspiraling process and the
problem I think that we fallinto is we don't understand how
to explain this to patients,because we go directly to the
weight and it's critical and wehave to fix that.
(25:40):
But here's what patients hear,no matter what you say, and it's
critical and we have to fixthat.
But here's what patients hear,no matter what you say.
You think I have an eatingdisorder.
No, I don't.
What I'm saying is that weightrestoration is key and you fall
into this process of low weight,inability to eat, pelvic floor
doesn't work.
Stress making this all worse.
And, from my standpoint, whenwe're looking at a cyclic
process, I don't want to breakthe cycle at just one point.
(26:04):
I want to blow up that cycleand I think the best way to do
that is to engage all of usphysician practitioners,
behavioral therapists,psychologists and dietary
experts because that's reallythe only way we're going to get
them better.
So I like to say, can stressplay a role?
At the beginning, yes, I thinkmore so an irritable bowel and
(26:24):
pelvic floor.
But over time, constipation canlead to more stress, which
leads down this pathway of doom,as I like to call it.
But we can fix this problem.
Dr. Megan Riehl (26:33):
We can bust that cycle.
Kate Scarlata (26:36):
I think the notion of restricting food.
Patients don't realize thatthat impacts the motility and is
going to bring them down.
Like your efforts are goingbackwards, you know you're not
going in the right direction.
That whole motility effect it'sa muscle, it needs nutrients
and fuel and that message hasn'tgotten out to them strong
(26:59):
enough.
I don't think and I'mconstantly saying this to
patients you need the energy foryour body to work.
It's just so important.
Darren Brenner, MD (27:08):
Even there, when we talk to practitioners to
put this in a little bit moretechnical terms, I tell my
patients even if you can justeat a little bit, try and graze
throughout the day, it's thegastrocolic reflex.
Patients go to the bathroom, orI should say patients,
individuals go to the bathroomfirst thing in the morning and
after meals.
When people come in they say Ieat and I poop, that's
completely normal because it'sthat reflex.
(27:29):
That's that increase for thepractitioners of high amplitude
propagative contractions.
And then we have medicationsthat we use that activate GCC
receptors, the secretogogslinacletide, placanetide.
These are activating the samemechanisms that food does to
help us go to the bathroom.
So at the end of the day,having a bowel movement, food is
key and essential.
Kate Scarlata (27:49):
Absolutely Good point.
Dr. Megan Riehl (27:51):
And the dream team approach of incorporating
several differentmultidisciplinary specialists is
so critical here because it isanxiety-provoking when you've
gotten into the cycle and that'swhere you know, in addition to
your treatment as the physician,Kate's treatment as the
dietician, my treatment as thepsychologist we're going to
(28:13):
utilize cognitive behavioraltherapies that are specific to
those GI concerns that you have,the avoidant behaviors, the
fear of reintroducing food.
So there are treatment optionsout there to certainly break
these cycles.
It's just a matter of gettinginto the hands of that right
team.
And so if you haven't foundthat and Dr Brenner is
(28:34):
explaining the cycle and you'relistening and just nodding your
head, going yes, yes, yes, yes,that's me Keep reaching out for
those strategies and even in ourbook we give you a ton of
resources to help create yourown dream team.
Darren Brenner, MD (28:49):
Yeah, Megan, if I may.
I'm sorry.
If I can add one more point, Iapologize, just for the
practitioners and the patientsalike.
If you have this type ofconstipation, please, from the
practitioner standpoint, behonest with your patients.
Tell your patients you can'tfix this alone.
Patients don't expect thepractitioner to be able to fix
this problem with medicine.
It doesn't work.
So we have to be realistic inthis process.
Dr. Megan Riehl (29:10):
Yeah, we have to all work together for the
sake of the patient's well-being.
Kate Scarlata (29:17):
IBS-C, or irritable bowel syndrome with
constipation, is a commoncondition in which people
experience constipation, alongwith other belly.
Symptoms like pain, bloatingand discomfort Sound familiar.
Many people with IBS-C arewilling to give up key parts of
their lives in exchange forsymptom relief.
(29:38):
And because the causes of IBS-Cmay differ for each person,
there is no one-size-fits-alltreatment approach.
If you're suffering from IBS-C,you may have to try a number of
different medications beforeyou find the right one for you.
So don't be okay with justfeeling okay.
If you have IBS symptoms thatcontinue to bother, you, talk to
(30:01):
your healthcare provider tofind out if your current
medication is right for you orif it's time to try something
different.
The more you know about IBS-C,the better prepared you will be
to speak with your doctor aboutthe right treatment option for
you.
Dr. Megan Riehl (30:18):
And as we shift to some other kind of potential
factors when it comes toconstipation, can you talk a
little bit about intestinalmethanogen overgrowth and its
potential relationship toconstipation?
What is it, how do we test it,how do we treat it?
Darren Brenner, MD (30:33):
What is it?
That's hard to define.
I think we're in the fledglingstages of understanding these
things and truly understandingour microbiomes.
People come in every day.
They're like, like I saidearlier, can I just take a
probiotic, fix my microbiome?
I do personally think that thegut microbiome is the gatekeeper
to everything, not just GI,allergy, immunology, pulmonary
(30:56):
issues, rheumatologic issues.
But the reality of thesituation is I'm going to
minimize, and I don't mean to.
It's not as simplistic as thehuman genome where we can map it
.
The gut microbiome is differentfor everybody and it changes
with very simple perturbations,like I said, just as simple as
changing our diet.
So I think we are really in thefledgling stages, we're at the
(31:17):
base of the iceberg andunderstanding it.
So I don't think we know itwell enough to manipulate it.
But one thing that has beenelucidated is this idea of emo,
and I'm glad you bring this up,megan, because I think everybody
just lumps this in to the SIBOcategory, and it's not.
It's something completelydifferent, which is why the
acronym has changed.
Remember, ladies and gentlemen,sibo is small intestinal
(31:42):
bacterial overgrowth.
Now I stress the small and thebacterial, because when we go to
emo, those disappear.
Emo is intestinal.
Ie.
It may not be in your smallintestine, it may be in your
colon.
Methanogenic these are notbacteria.
They are archaea or primitivesingle-celled organisms that
(32:04):
overgrow, and so you can findthese things in the GI tract.
And they are methanogens,meaning that they produce
methane, and methane has beenshown in clinical trials to slow
gut motility.
So I think about these as apotential trigger for slow
transit constipation.
But they're also associatedwith some of the abdominal
(32:25):
symptoms you experience, likethe bloating and the distension,
and in many cases they aretreated differently than SIBO.
So people come and they sayI've been treated for SIBO and
SIBO, and SIBO and SIBO and it'snot doing anything.
And it may be because it is not, again, small bacteria but
intestinal methanogens.
Now the best way to test forthese right now is with breast
(32:46):
tests, and you can use glucoseand lactulose breast tests, and
these are done in some clinicalpractice or academic center labs
, but there are multipleproprietary institutions out
there that you can get this kitand do it at home while you're
watching TV on your couch.
The accuracy of these tests,from my standpoint, still has
yet to be elucidated, so I dolike to tell everybody if you
(33:09):
get a positive test for SIBO oremo.
Don't put all of your eggs intothis basket.
Like I said before with theVenn diagram, do not focus
solely on this.
This may not be the onlyproblem or even the problem that
is causing your symptom profileand I mention that because I
come to a lot.
I see a lot of patients whocome in.
They're like I haveconstipation because I have
(33:30):
intestinal methanogenicovergrowth, and then I do a
couple of different tests and Isay you may have intestinal
methanogenic overgrowth and emo,but there are a few other
things going on that we have tofocus on as well.
Kate Scarlata (33:41):
That's right, like, is it the chicken or the
egg?
You know, like, what's causingthis emo, a motility or
something else, right?
Darren Brenner, MD (33:50):
Right.
Where is it matters?
Because when we think abouttreating and we treat primarily
with antibiotics there's someherbal therapies that have some
data, some studies we didrecently in Northwestern for an
herbal called the Atrantil, butthe therapeutics and what you're
going to be able to use toimpact emo is probably going to
(34:11):
be shown to be quite differentthan what we use for SIBO.
Kate Scarlata (34:11):
Can you just talk a little bit about Atrantil
, because I get a lot ofquestions about that.
In your study, did it reducemethane?
I know there was a reduction inbloating, right, but did it
reduce the actual methane levelsas well?
Darren Brenner, MD (34:24):
Yeah, it's a really good question because
that's what we're looking at.
We're looking at symptoms andcorrelations to methane
responses in two differentfashions.
One was did it just absolutelyreduce methane?
And two was did it lower itbelow the threshold of normalcy,
ie 10 parts per million?
Now I will say truth inadvertising.
This is a small study.
(34:45):
It's an open-label study.
It had to be done in one yearand it was done during COVID and
so every patient who got atransult knew that they were
getting a transult.
So it wasn't compared toplacebo.
But I'm fine with that becauseI call this a case-based,
real-world analysis of this typeof therapeutic and that's what
people are doing with probioticsevery day.
(35:05):
We use the NIH PROMIS scales asour threshold to determine who
responded, and we wanted to,because if we're truly treating
intestinal methanogenicovergrowth or emo, we don't
expect it to improve some of theother PROMIS items like reflux
or dysphagia.
And it didn't like reflux ordysphagia and it didn't.
(35:26):
What the patients responded towas we saw significant
improvements in bloating andabdominal distension and
discomfort and a very closetrend.
It didn't meet statisticalsignificance but it was close
for constipation the cardinalsymptoms of emo.
We also looked at adequaterelief.
We know this is a validatedendpoint.
The vast majority of ourpatients had irritable bowel
syndrome, were positive formethane and more than 50% of
(35:47):
patients endorsed adequaterelief at the end of a month of
treatment compared to how theywere at baseline.
The next thing is the safetyprofile.
We had really no serious severeadverse events whatsoever.
The interesting part was we sawreally no changes in methane no
absolute changes over time, andcertainly there were only about
three or four patients thatdropped below the 10 part per
(36:08):
million threshold.
Now, the vast majority ofpatients that we enrolled
weren't very high above thatthreshold.
The price per million was inthe probably 10 to 20 range, so
there could have been a flooreffect.
But it also begs the questionwith this therapeutic, which
does contain some barkPeppermint oil.
I think many of ourpractitioners and listeners are
familiar with what peppermintoil can do.
(36:28):
So some things we don't know alot about, some things we do,
but very natural interventionsthese are the things that we're
trying in these patients.
Awesome.
Dr. Megan Riehl (36:36):
All right.
So you mentioned this.
You're starting to talk alittle bit more about the
potential things that patientscan try to help with their
constipation, and one thing thatwe frequently hear is fiber.
So do you have a go-to fibersupplement as a
gastroenterologist that you feelcomfortable recommending to
your patients, or do you justsend the patients to one of your
(36:56):
fabulous dietitians and havethem help with fiber intake?
What's your approach?
Darren Brenner, MD (37:02):
So my dietitians are fabulous, but if
I sent everybody who neededfiber for constipation to them,
woe to the patients who reallyneed to see them.
So, yes, I do have a go-to andI think in GI there are two
schools of thought people whobelieve in fiber and people who
don't, at least based on studiesthat came out of the University
of Michigan, where you practice, looking at what practitioners,
(37:22):
specificallygastroenterologists, recommend
as first and second lineinterventions.
So I will give all of thesesynonyms for the one I use
Plantago ovato, isfagula in myworld.
Ground up corn husk, okay.
Psyllium soluble, minimallyfermentable, gel-forming fiber.
(37:43):
I think this is the best.
This is my go-to and this isthe one that I recommend, based
on clinical literature andclinical experience, for
patients with chronicconstipation and irritable bowel
syndrome or constipation.
Now, the vast majority of thepeople that I see do come in
with a complaint of bloating anddistention and I don't minimize
(38:03):
that even this one has thepotential to cause this.
So I always start with the old,start slow and low and titrate
from there.
I do not try to pound 20 to 30grams of fiber, as recommended
by everybody, into somebody onthe first day.
They will blow up like aballoon and want to kill you.
(38:23):
I've had this experience.
I have tried the differentfibers and supplements at DDW
and then laid on the floormiserable, because I'm not
afraid to share the fact thatfor 20 years I have suffered
from post-infectious irritablebowel syndrome.
So I am not only a patient, I'malso a client and if I use
fiber, this is the one I use.
I think it is the mosteffective with the least
(38:44):
likelihood to give gas andbloating.
And again, I start very slow, acouple tablespoons a day with
meals and I work my way up fromthere.
Dr. Megan Riehl (38:51):
Perfect.
So take heed, so that you tooare not on the floor low and
slow and work your way up to theproper daily dose.
And then when do you escalatefrom some of these?
Because that's over-the-counter, right, we can get
over-the-counter supplements andmedications when do you
escalate to something like someof the prescriptions you've
(39:14):
mentioned earlier?
Darren Brenner, MD (39:15):
Yeah, you know I'm a big fan of
over-the-counters.
When we published oursystematic review a couple years
ago on all the over-the-countertherapies, I'm a big fan of PEG
3350.
Everybody starts there.
So if they don't want fiber orthey fail fiber, everybody
starts there.
Now when I say I'll fail fiber,I'm also talking about Kate's
dietetic interventions.
So I talk about kiwis, mangoes,prunes, with everybody that
(39:36):
walks in the door.
I know our dieticians are bigfans of chia seeds as well.
So I do like people to gohealthy and natural first.
When people fail PEG, that'swhen, in many cases, I will
start thinking about theprescription therapeutics.
That does not mean that I'manti-Sena or bisacodyl.
I use these more as rescues.
I'm not adverse to magnesium.
(39:58):
A lot of my patients havealready come in and failed
magnesium because it's a naturalsupplement and they've tried it
.
But where I really start todifferentiate is with the
severity of the abdominalsymptoms the pain, the bloating,
the discomfort.
Prevention none of theover-the-counter therapies have
ever been shown to improveabdominal symptoms and in fact
(40:29):
in the clinical trials some havebeen shown to worsen them.
So when somebody walks in thedoor and says my predominant
symptom is pain, discomfort andbloating, yeah, I can get my
bowels under better control, thefrequency, texture, straining
and complete evacuation with theover-the-counter.
That's when I go to theprescriptions, because the data
is much more robust for helpingthose abdominal symptoms.
Kate Scarlata (40:44):
Awesome.
I don't want to get totallyinto brands, but is there one
that's more?
First line.
Darren Brenner, MD (40:51):
Yeah, for the prescriptions, Kate, it
comes down to my four Cs, butI'll focus on the first two,
which are cost and coverage.
In many cases, unfortunately,in 2024, and I think all of us
practitioners hate this what weprescribed is dictated by what
insurance gets as their initialtiers, and that's what we have
to give these individuals, andthe differences can be hundreds,
if thousands, of dollars, andso we're a little bit restricted
(41:13):
in that process.
So, realistically, that's mygo-to.
Kate Scarlata (41:17):
Yep, that makes a lot of sense.
I know I just switchedinsurance so I'm hearing you.
It's like a whole new world.
I'm trying to figure out what'scovered and what isn't.
I don't think I'm going to letgo of the milk dud analogy
earlier.
I keep thinking that was one ofmy favorite candies growing up.
So, yes, if you areexperiencing poops that look
(41:40):
like milk duds and you haveconstipation, as Dr.
Brenner has explained verybeautifully, there are some diet
and lifestyle interventionsthat I often will use with my
patients, so in individuals thatI consult with.
So I'm just going to brieflyrun through some of these as a
review.
Green kiwi fruit is my go-to andI tell people to buy it in bulk
(42:03):
.
Wash it, chop it up, keep it inyour freezer.
It's a great.
You can just throw it into asmoothie.
It's two green kiwi fruit thathave the best sort of efficacy.
You can keep the skin on in asmoothie.
You're not even going to see itor taste it and it's fine.
It's extra fiber for you.
Mango has excess fructose, whichis very osmotic.
So Dr.
(42:24):
Brenner mentioned thatSorbitol-containing foods like
prunes or apricots peaches thosealso have a lot of osmotic
effects, pulling water into thegut, that may soften up your
stool.
I am also a huge psyllium huskfan so I add it to my smoothie
and I just go titrate slow.
I get Kate Farms (note (42:44):
should be Kate Naturals).
It's a powdered psyllium huskand about a teaspoon is four
grams of fiber.
I think that's a great startingpoint for most people and then
you can titrate that up to kindof see where you are.
But, as Dr.
Brenner mentioned, it's soluble, which tends to be a more
tolerable type of fiber.
It's not adding a lot of bulkto the stool.
We already have a lot of bulkto pass.
(43:05):
It's low fermentable, which isgreat, and then that viscous
property is great because itsops up extra fluid softening
stool.
It's low fermentable, so itstays intact in the colon to do
the job that it does.
So that is absolutely myfavorite favorite.
The other idea is a squattypotty.
If you talk to any GI dietitianthey all have them, including
(43:27):
me.
I have a streamlined one that'skind of see-through, very, very
posh.
But we talk about the properpoop position in our book on
actually page 329, so that youcan kind of see you want to
raise those knees above yourhips, open up that rectal canal
angle and let things flow alittle bit more easily into the
(43:48):
porcelain throne.
I love that.
Always make sure, as Dr.
Brenner mentioned, fiber shouldbe titrated up slowly.
Let your body adapt.
There's a big ecosystem goingon, trillions of microbes in the
colon and they're going to lovethat fiber you're upping in
your diet.
So just go slow.
Lots of fluids to have yourbody adjust.
And then exercise is anotherreally good thing.
(44:09):
So keep your body moving.
I think a good long walk a lotof people will be like, oh, come
home and be ready to hit thetoilet.
So I think that's important.
And another really importantpoint that Dr.
Brenner mentioned was eatingregularly.
So we do have that gastro colicreflex after we eat.
That stimulates colonicmotility.
So if you're skipping to avoidsymptoms, you're not going to
(44:33):
take advantage of that gastrocolic reflex.
So eating regular meals is key.
So that's my little spiel, Dr.
Riehl.
Hey, is the Squatty Potty likea real thing?
Dr. Megan Riehl (44:44):
I saw it on Shark Tank and he said you know,
yes, I endorse this thing.
(45:07):
So it was actually from Dr.
Brenner where I was able toreally, you know, remind our
patients of the value andimportance of our posture and
our behavior as well, on theporcelain throne.
So thank you, Dr.
Brenner.
A couple other words about, asyou mentioned, we go back to
that cycle that people get intoand recognizing that stress can
(45:31):
be a big factor and sometimesthe stress is completely related
to just your bathroom habits,and so if you're somebody that
does, you're afraid to go to thebathroom at work because you're
like, ah, people are going towonder what I'm doing in there
and we have Poo-Pourri now, likeso it's so important to not
(45:52):
miss your body's cues that it'stime to go, and when you do, you
start to really impact thatbrain-gut connection where the
brain is saying like, hey, wegot to go, I got signals from
down below and you're not going,so now I'm going to have more
clenching, spasming, anxiety,pain.
So it's so important that welisten to those cues.
(46:14):
And the other side of this isreally about balance that you
know if you're havingconstipation, balance in life in
general which is good for allof us, whether you have
constipation or not is so key,and so that comes in the form of
self-care and so practicingrelaxation.
And you can really up this bydoing gut-directed relaxation or
(46:37):
gut-directed hypnotherapy,which is actually an
evidence-based behavioraltherapy to help with the
management of constipation, evenif you don't have access to a
GI psychologist to guide youthrough this.
The world of digital behavioraltherapeutics is evolving, and
so there's an app that you candownload now the Nerva app.
(47:00):
That's a gut-directedhypnotherapy app that provides
you with a behavioral strategyto really address the
restoration between the brainand the gut that can become so
dysregulated with our gut healthand, you know, for a variety of
reasons, as we've hit on,whether it be our nutrition, our
stress, the mechanics of ourtoileting and our motility.
So there's lots to considerhere and finding that balance
(47:25):
through both movement andrelaxation.
You guys have all heard mealready talk about the benefits
of diaphragmatic breathing, butthat's a beautiful strategy that
can help to quickly break thatstress cycle, while you then can
employ a variety of othertechniques and strategies.
So we just want to be mindfulthat constipation is not a one
(47:49):
thing is going to fix it all alot of times, and so we hope
that our guest today, Dr.
Brenner, gave you lots toconsider and maybe ponder while
you're on that porcelain throne,but don't ponder for too long.
A lot of times, withconstipation, people are sitting
on the toilet for far too long,and maybe, Dr.
(48:10):
Brenner, how long shouldsomebody sit on the toilet
before they decide you know what, now's not the time and they
get up and go?
Darren Brenner, MD (48:16):
I usually tell people five to 10 minutes
and override your brain.
You can override, lift yourlegs and walk away, and I want
you to do that.
And a lot of times people havea lot of difficulty and, Megan,
that's where you can come in andhelp assist some of these
people.
It's getting over thatperseverative piece and
overriding that urge, knowingthat you will try again later
and hopefully have more successat that point.
Perfect.
Dr. Megan Riehl (48:37):
All right.
Well, we have learned.
I have learned so much from youtoday, and I hope our listeners
have too, and as we wrap upthis episode, we like to ask all
of our guests the followingquestion okay, what is something
that you, Dr.
Darren Brenner, prioritize whenit comes to your own overall
health and wellness?
What do you do?
Darren Brenner, MD (48:57):
That's a great question.
I will honestly andwholeheartedly admit that I
spend all day recommending toall of my patients that they eat
these very healthy, balanceddiets.
And I know the two of you havebroken bread with me in the past
and I'm probably anything, butI love my food.
I love my junk food.
There's the live to eat and eatto live, and I live to eat.
(49:18):
So I focus on the exerciseaspect.
As Kate mentioned, people tellme all the time I just can't
find the time to exercise.
Please, please, please, please,please, please, please, please,
please, please, please, please,make the time 30 minutes an
hour.
Just get up and go for a walk.
I will do my workout, if I haveto, at midnight and then go to
(49:39):
bed.
But it's amazing how much theexercise can help, just not in
the gut motility per se, as youmentioned, but also on the
psyche side and the way you feel.
I wake up every morning thenext day feeling much better if
I worked out than if I hadn't,and I think that alone can be a
major contributor overall to notonly your gut health but just
(50:00):
your health in general.
Dr. Megan Riehl (50:01):
So this man is one of the busiest.
We were lucky to grab time fromhim.
But I think it just begs tokind of show the benefit that,
even if you are living a very,very busy lifestyle,
prioritizing your own time forself-care and moving your body,
it's going to give you theendorphins, it's going to help
you be more productive in yourday-to-day work life, school
(50:25):
life, mom, dad life.
Thank you for elucidating thebenefits of that.
Kate Scarlata (50:32):
Yes, I love that I'm all about the exercise too,
but I'm going to work on.
I think we're going to have alittle nutrition consult the
next time I see you what we calla gentle diet cleanup.
Darren Brenner, MD (50:46):
Which is funny, Kate, because I'm going
to call you out here, becausethe next time you see me, we're
sharing a dinner at Fogo do Chão.
All you can eat Braziliansteakhouse.
Kate Scarlata (50:54):
I know I have to .
Really I'll have to clean up myact that evening.
That is so funny, it's true.
Oh my goodness, this wasphenomenal and so helpful on so
many levels.
You've covered everything Ithink about constipation and
more.
So thank you so much for comingon, Dr.
Brenner.
We appreciate your time,especially knowing how busy you
(51:16):
are, and keep making the GIspace a better place to work in.
Keep doing that wonderfulresearch.
It's making a difference in thelives of people living with GI
conditions.
So thank you, it is my pleasure.
Darren Brenner, MD (51:31):
Thank you for having me.
I really do appreciate it.
Dr. Megan Riehl (51:34):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at the Gut Health
Podcast, where we'd love for youto share your thoughts,
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Whether you're ahealth-conscious advocate, an
individual navigating thecomplexities of living with GI
issues, or a healthcare provider, you are in the right place.
(00:22):
The Gut Health Podcast willempower you with a fascinating
scientific connection betweenyour brain, food and the gut.
Come join us.
We welcome you.
Dr. Megan Riehl (00:37):
Hello friends, and welcome to the Gut Health
Podcast, where we talk about allthings related to your gut and
well-being.
We are your hosts.
I'm Megan Riehl, a GIpsychologist.
Kate Scarlata (00:50):
Hi, I'm Kate Scarlata.
We have an exciting podcast foryou.
Today, w e are talking allabout constipation, a condition
that impacts up to one in fiveAmericans.
A recent survey study showedthat three out of five people
living with constipation neverdiscuss their symptoms with a
(01:10):
healthcare provider, and we arehere to change that, because
there's many new and noveltherapies for constipation,
including taking vibratingcapsules that can help improve
your exit strategy.
Dr. Megan Riehl (01:25):
So our guest today is a professor of medicine
at Northwestern University andhas Wolverine roots, go blue,
and I've had the privilege ofworking with him very early in
my career.
Dr.
Darren Brenner is a belovedgastroenterologist to his
patients and has a trueunderstanding for the
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complexities of living life withGI disorders.
Not only does he travel theworld lecturing on disorders of
gut-brain interaction, like IBS,which we talk about a lot and
more, he is a researcher and anexpert in GI motility and pelvic
floor disorders.
We are thrilled to have himwith us today and we have no
doubt that everyone listeningwill be entertained while we
(02:06):
explore this topic of notpooping or constipation.
So welcome, Dr.
Brenner.
Darren Brenner, MD (02:13):
Thanks Megan , thanks Kate.
Yeah, it's amazing what I dofor a living, isn't it?
Dr. Megan Riehl (02:16):
Yeah, who would have thought, you know?
But we love it.
Kate Scarlata (02:19):
We do love it.
All about poop.
So, in the world of gut health,we really like to break through
the misconceptions and mythsout there because, as you know,
tiktok is full of them.
So we would love to have yourexpertise here.
Can you myth bust for us what'ssomething you'd like to dispel
with our audience?
Darren Brenner, MD (02:40):
Yeah, so I think this is something I see
all the time.
This is something patients comeback with questions and
physicians alike, and it'sreally some myths and
misconceptions on things thatwork and don't work and can be
safe or unsafe for treatingconstipation.
And this is a multi-billiondollar industry with almost
little to no regulation,especially in the
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gastrointestinal space.
If somebody goes to the storeand wants to look for a
probiotic, the packages saypromotes gut health or promotes
gut immunity, but really can'tmake any claims about this
particular illness.
And there have been some recentstudies that showed up to a
quarter of individuals withconstipation are trying to treat
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their symptoms with probiotics,in many cases probiotics alone,
and, I'm sad to say, at leastin 2024, there really isn't a
lot of evidence or data tosupport that.
So I guess that's mylong-winded way of saying if you
think probiotics are going tofix your constipation, it's very
unlikely.
Now, on the flip side is thetaboo, and this has been around
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for 40, 50 years.
There've been lots of papers.
We're still writing myths andmisconceptions about the use of
stimulant laxatives, things likeSenna or Bisacodyl.
We've been told that they'llcause cathartic colon or dead
colons or atonic colons or longcolons or melanosis coli or
colon cancer, and the list goeson and on and on.
But the reality of thesituation is that in standard
(04:10):
doses, these therapeutics arevery safe and very effective.
So if you're a patient who aretaking standard doses of Senna
or Bisacodyl, I don't want themto worry that anything is going
to happen to their GI tracts orthat these are, in any way or
shape, harmful for them in thelong term.
Kate Scarlata (04:27):
I am so, so glad you said that, because I get
that question all the time andeven when I'm amongst other
gastroenterologists, I feel likesome of them believe that
there's a problem there, but theexpert here is saying, no,
don't worry about that.
And I think that is a reallyimportant message for people out
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there who find that Sennareally works for them, and then
someone tells them dial it back,you can't be on that.
So thank you for that.
That's huge.
Dr. Megan Riehl (04:57):
It really highlights the individuality of
everyone's gut and that yourtoolbox is going to look
different from the next person,from the next person, from the
next person.
Darren Brenner, MD (05:08):
Absolutely.
I mean, I think that's thebeauty of what we do.
You know, people are asking foralgorithms.
We try to put these algorithmstogether, but, megan, to your
point, everybody is anindividual unto himself or
herself, and so the treatmentshave to be different.
I think that's what makesmedicine, especially treating
disorders of gut braininteraction, so fascinating.
Kate Scarlata (05:25):
That's right, I agree.
So let's just dial it back withconstipation.
Can you define constipation forthe lay audience?
Because I have patientssometimes that say, oh, I didn't
poop in the last 12 hours, so Ihave constipation.
Or if they skip a day ofpooping, they have constipation,
but that's not true.
(05:45):
Day of pooping, they haveconstipation, but that's not
true, right?
Darren Brenner, MD (05:47):
That's right and it's just like we mentioned
.
It's different for everybodyand I mean that from a
practitioner and a patientstandpoint.
Unfortunately, to ourconversation earlier about
TikTok, the lay person has beentaught that they have to have
one perfect what looks like asausage ball movement every day,
and that's just not reality andI think that's actually more
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the exception than the norm.
And so when we think aboutconstipation, at least
historically, we break it into alot of different symptoms,
because it's different strokesfor different folks and
absolutely frequency does play arole here, but normal.
We have found, initially inEurope and more recently in the
United States, that about 95% ofthe US population has a bowel
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movement anywhere between threetimes a day to three times a
week.
Now that sounds extreme, thatnorms can be three to 21 bowel
movements a day, but that is thereality of the healthy average
individual in the United States.
We talk about texture.
I think those of us in academiause the Bristol stool form
scale.
I think a lot of people andpatients who focused on their
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bowels know what this scale is,but I don't think the average
individual does, and it's ascale that defines stool based
on its texture and not to grossanybody out during this podcast,
but we really defineconstipation as things that look
like milk duds or baby roofbars, and I've been using that
analogy probably for two decadesnow, but it's because it really
(07:14):
hits home.
I think people can relate towhat those types of stools look
like.
We talk about subjectivesymptoms.
Do you strain to go to thebathroom?
Do you not feel like you geteverything out when you go,
which I think is one of thehardest things to overcome?
Do you feel obstructed?
Do you feel a heaviness or apressure in your pelvic floor?
You feel like you have to go tothe bathroom and you just can't
(07:35):
get it out.
And then the taboo that nobodywants to talk about do you need
to perform manual maneuvers andI hope nobody's watching this
during breakfast, lunch ordinner because I'm going to
describe these but we talk aboutmanual disimpaction having to
stick a finger into your bottomand try to rake or pull the
stool out.
Or, for women, we talk aboutsplinting having to take a
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finger or two and put them inthe vaginal cavity and push
posteriorly, which reduces allkinds of anatomical variance
that can obstruct the stool fromcoming out.
And again, some people willcome in with all of these, some
one or two of these, and so itis a different I would say du
jour for everybody.
When we meet these patients, Ialways like to talk about a
specific type of constipation,because I do see these
(08:19):
individuals regularly and Ithink they suffer for a long
time and these are the peoplethat are defined with diarrhea,
because they come in and theirchief complaint is I have 10, 15
bowel moments a day.
When you start to tease outthese other symptoms, they say I
have 10 hard pellets or I'mstraining, or I feel incomplete
evacuation, and what they'rereally having in many instances
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is constipation with overflow.
There are hard impacted stoolsat the bottom of the GI tract.
The stuff above it gets looserand it finds a way to leak
around it, and unfortunately,these people are treated with
anti-diarrheals, which justmakes the process worse.
And so in many instances, whensomebody comes in and we're not
sure if they have constipationor diarrhea, I think your best
(09:03):
friend can be an abdominal x-ray, because you'd be surprised how
many times you will find thatthere's just a significant
amount of stool in the colon,which will identify specifically
that this is more constipationthan diarrhea.
Kate Scarlata (09:15):
That's awesome.
And when they go in for anx-ray, is it a KUB x-ray?
What would they ask for withtheir physician?
Darren Brenner, MD (09:23):
It's a KUB and I think that can do a couple
of things.
I think we see as an overlap,where people are constipated, a
lot of abdominal complaints likeabdominal bloating and
distension.
These are two very differentthings and I think you can
really differentiate betweenthem with that KUB, because not
only do we see the stool contentof the colon but the gas
content.
(09:44):
So many times my patients comein and they say, as the day goes
on, I look six, nine monthspregnant, I'm full of gas.
We shoot the film and I canbring them back to the office
and say look, here's yourabdominal x-ray, here's what the
stool looks like, but there'sno excess gas, which sends us in
a completely differentdirection.
Kate Scarlata (10:00):
That's awesome.
I'm glad you do that because,again, I think not everyone
wants to do those x-rays and Iusually am in favor of them
because most of my patientsactually have constipation, so
it's kind of interesting.
So there's different types ofsubtypes of constipation.
You know IBS-C or chronicidiopathic constipation, slow
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transit what's all this "garb?
Darren Brenner, MD (10:28):
Sure, let's talk about the hodgepodge and
how much I can confuse you whenit comes to constipation.
And I will preface that bysaying that when we're in
medical school or, I think,dietary school or psychology
school, what we're always taughtis this If you're not sure
what's going on, take morehistory.
And if you're still not surewhat's going on, take more
history.
And if you're still not surewhat's going on, take more
history.
(10:48):
And now I get to go back to allof my professors 20 years ago
and say, when it comes toconstipation, that may not
necessarily be true Becauseunfortunately, what we have
learned and what the clinicaltrial shows is this You're not
going to be able todifferentiate one person's
constipation from another basedon their subjective symptoms.
But it is important to try andfigure out what types of
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constipation are underlying thepatient's symptoms, because I
think the biggest fallacy isthat somebody focuses on one
subtype.
They say aha, I think you haveirritable bowel syndrome with
constipation, and they focusright there.
And when I think ofconstipation, I really define it
along a Venn diagram, becausethere's a lot of overlap,
especially at the academiccenters.
So if you ask me whatconstipation is, I'll tell you
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it's an overlap of fourdifferent subtypes.
And I start with the secondarycauses of constipation.
And yes, these are things thatwe can glean from a history and
a physical exam.
So, do you have a risk factorfor obstruction?
Are you of colon cancerscreening age?
Could this be, unfortunately, amass or some sort of
obstructive physiology?
Could it be related to anendocrinopathy?
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Do you have diabetes,hypothyroidism?
Could it be a medication?
We talk about opioids andbenzodiazepines, but in reality
there are much more commontherapeutics out there,
especially in the cardiovascularclass beta blockers, thiazides,
ace inhibitors.
And then we need to realizethat older literature shows that
if an individual is on six ormore medications at any given
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time, that threshold of sixincreases the odds ratio that
somebody will developconstipation.
In my world, where I see aneuromyopathic disorder,
scleroderma, parkinson's is ahuge one MS, als, these are all
things we can think about ascauses, but I want to caution
your listeners if you can defineone of those, don't stop there,
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because then we want to thinkabout the three other categories
.
Kate, you mentioned oneirritable bowel syndrome with
constipation, and I call thisone the trap.
Okay, this is something thatmost young individuals come in
they complain about constipation, a little bit of bloating.
We snap our fingers, we say youhave IBSC, let's treat that.
And then 40 to 50 years laterthey come into our offices and
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we say it could be somethingelse, like slow transit,
constipation the best name inhistory because it defines
constipation because things aremoving too slowly through the GI
tract.
And then obstructive physiology,what we call evacuation or
functional defecation disorders,which can be anatomical
problems rectus seals, enterusseals, intussusception which can
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anatomically block the stoolfrom coming out.
And then the most common one wetalk about, which is
dyssynergic defecation, orpelvic floor spasm, or a nismis
where the muscles in the pelvicfloor do not work and so when
you try to go to the bathroom,instead of those muscles opening
up to allow stool to comethrough, then they open a little
bit, not at all, or go intospasm and impede the ability of
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stool to come through.
Then they open a little bit,not at all, or go into spasm and
impede the ability of stool tocome out.
And it's very important earlyin the course to define this
disorder, because this is thedisorder that will not respond
to therapeutics like laxatives,and I think we're going to come
back to this a little bit later.
Dr. Megan Riehl (13:59):
And it won't respond to some of our
behavioral strategies.
It really requires, then,bringing on that pelvic floor
physical therapist.
And so you make such a hugepoint here that especially we
see this constipation moreprevalently with women.
And so if they're told you haveconstipation and then they're
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not consulted by a pelvic floorphysical therapist or their
gastroenterologist hasn't done aphysical exam or some of the
additional workups that areavailable, like diphagraphy or
anal rectal manometry, thesepatients are going to suffer
more for longer and that's adisservice.
Darren Brenner, MD (14:39):
And that's part of our concern as
practitioners.
Our algorithm hasn't changed in20, 30 years and when we talk
about diagnostic testing, theaverage individual will probably
get a colonoscopy, but thefirst test recommended is
anorectal manometry and blueexpulsion testing.
Realistically, the first testrecommended is a digital rectal
exam, but I think we do a verypoor job training our trainees
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on how to do that.
I always say the digital rectalexam is only as good as the
finger that's performing it andthus, if you're not comfortable
doing that exam, we really don'twant you invasive.
We can use the anorectalmanometry to better define
anorectal physiology.
And, Megan, you opened thatdoor talking about the pelvic
floor and I will walk throughthis door anytime I've given the
opportunity.
(15:22):
So please allow me to tangent alittle bit, because I always say
in my lectures and I always saywhen we're talking about these
types of things, I want to talkabout something that's near and
dear to your heart and that is ahistory of trauma, whether it
be physical, sexual or emotionaltrauma or abuse.
Because the reality is, the vastmajority of practitioners do
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not ask about this, and thisplays a fundamental and key role
in constipation, because thereality of the situation is this
.
If your patient has a historyof physical, sexual, emotional
abuse or has undergone or gonethrough some form of trauma and
they have constipation, thepretest probability that their
pelvic floor doesn't work, basedon clinical literature and
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anecdotal experience, is higherthan 90%.
And while with pelvic floorproblems we recommend the
physical therapy, the reality ofthe situation is, if we do not
mind pardon the pun thatbrain-gut connection, these
patients with physical therapyhave little likelihood of
success for improving theirconstipation symptoms.
(16:28):
So I beg all of your listeners,I beg all of my colleagues
around the world when you see apatient with constipation, ask
about this, because you willhave to target and focus on that
brain-gut interactionassociated with the trauma as
well.
Dr. Megan Riehl (16:41):
That's such an important point and, to your
point, sometimes we're notcomfortable doing the rectal
exam, and then there's an evenhigher prevalence that are not
comfortable to have thatconversation, and so I also beg
of you, as a listener, toadvocate for yourself to let
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your physician know if you dohave a history of trauma, and
even if your provider hasn'tnecessarily asked about it, they
likely will be very able andcapable of making your
experience with either yourmedical procedures or subsequent
questions more comfortable.
So it's a two-way street.
(17:22):
You know we want peopleadvocating for themselves, but
it's such a good point thatphysicians, especially in this
area, and primary care doctorsand NPs and APPs, we do have to
be very mindful of thatconnection between our brain and
our gut and our lifeexperiences.
Darren Brenner, MD (17:41):
And please do advocate for yourselves.
I ask all of my patients, as amatter of fact, if they have a
history of trauma, I let themsee the manometry catheters,
feel them, touch them, know theexperience, walk through the
process, because in many casesthese individuals are not
comfortable undergoing theprocedure and they're not going
to be comfortable undergoingpelvic floor physical therapy.
(18:02):
It is a very invasiveintervention and they have to be
aware of what's going to happenwithin that clinical practice
and in many cases and I thankyou and all of your colleagues
for this brain, gut, behavioraltherapists get involved and we
start there and then we gobackwards to the diagnostic
testing and the treatmentassociated with pelvic floor
dysfunction.
Dr. Megan Riehl (18:21):
And even if you're somebody that doesn't
have a history of trauma andyou're feeling a little bit
anxious about a doctor that says, okay, I'm going to do a rectal
exam now, or you know it's timefor a colonoscopy, you're not
alone in feeling anxious aboutthis, and we, even in our book
Mind your Gut, we put in acolonoscopy coping kit to
highlight, you know that youcould ask for certain music, you
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can do some breathing exercises, you can ask as many questions
as you want to yourgastroenterologist prior to any
of these procedures and you'llfeel more comfortable.
So those with a trauma history,and certainly the many that do
not have a trauma history, wewant you to be comfortable.
Your relationship with yourgastroenterologist is as about
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as close as you can be, and soyou want to have a really good
therapeutic dynamic across thespectrum of your time working
together.
Kate Scarlata (19:14):
I love that and I would say, you know, I love
that you show or go through thetesting with your patients,
because I'd certainly hadpatients just arrive at the
testing and like what are wedoing here?
So I think if you're a listeneras a patient or you're a
listener as a provider, it isimportant that you ask what the
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test entails and, as a provider,I always prep my patients like
this is the test, this is whatthey're going to be looking for.
It's important part ofunderstanding your pelvic floor,
but expect the following sothat they can decide you know,
or at least be prepped and notsurprised.
So one other question I wantedto talk about you have an
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individual with constipation.
What are some other red flagsthat would really prompt you to
say we need to do furtherinvestigations here?
Something else is going onbeyond just constipation.
Darren Brenner, MD (20:12):
Yeah, great question, Kate.
I think, first and foremost, ifyou're over the age of 45,
request that colonoscopy.
I can pretty much assure thegastroenterologist is going to
want to do that.
That is the new screening ageand we're going to want to take
a look to make sure there'snothing obstructive.
Now that does not and I stressthe term not mean that if you
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come in with new onsetconstipation over the age of 45,
that it is due to colon cancer.
I have found that very, veryinfrequently in my career.
As a matter of fact, havingprobably seen 20,000 people with
constipation, I can find thenumber of colon cancers that I
have identified on less than twohands.
Okay, so I don't want you toworry.
But that would be the firstthing.
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Let us know if there has beenrecurrent or an increase or
crescendo in bleeding, if thisis an acute change, if there's
unexplained or unintentionalweight loss.
These are big triggers that wewant to know about.
These are things that mayindicate something else may be
going on.
But think about lifestylefactors as well.
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Have you changed your diet?
If you change your diet, youshift your microbiome.
If you shift your microbiome,it may change the motility,
secretory and sensory patternsof your GI tract?
Or have you tried a newmedication?
Like I said, we talk about thebig ones, but there are hundreds
of medications out there thatcan cause constipation.
(21:33):
So let us know, and let us knowif something has changed,
because we may be able tocorrelate that specific change
with your new onset symptoms andallay your fears very quickly.
Dr. Megan Riehl (21:48):
All right.
So those are those red flags,and our listeners are going to
get really good at understandingwhat those are.
Again, we don't want you tohave a ton of anxiety.
If you do have a red flag, itjust is a good indicator that,
hey, you need to check in with adoctor and we'll go from there.
It doesn't have to mean thatthere's a cancer, and that
certainly is something that alot of people stress about,
which leads me to a segue hereto the brain-gut connection.
(22:09):
So you've mentioned thisconstipation can be a disorder
of gut-brain interaction.
So tell us a little bit fromyour gastroenterologist brain
and perspective how does thebrain-gut connection impact
constipation, and tell us alittle bit about what stress
does to that.
Darren Brenner, MD (22:28):
Yeah.
So you know, when I think aboutthe brain-gut connection, I
think about stress as it relatesto constipation.
I really take it out of thewhat's called slow transit
constipation component,irritable bowel syndrome.
We all know that stressexacerbates those symptoms and I
worry about my stress patientwhen it comes more so to the
(22:48):
disorders of the pelvic floor,and then I get into what I call
the sick cycle.
Pardon the pun again, but Ithink we as practitioners for
many years have poo-pooedconstipation as a nuisance
disorder and if you really takecare of these individuals, you
see it's much more than that.
It significantly impactsquality of life.
(23:08):
I can't get out of my house, Ican't leave the porcelain throne
.
I spend six, seven, eight hoursa day on that toilet and when
I'm not on the toilet, on thecouch perseverating about said
toilet because I feel likethere's still stool in there.
I'm afraid to go somewhere.
What if I get the urge?
What if I'm out to dinner withmy friends and I'm in the
bathroom for 30 minutes?
Is somebody going to comechecking on me because I think I
(23:30):
fell in the toilet or somebodyflushed me down the drain?
These are things that,realistically, I have heard over
and over again.
And the problem is when youstart to feel the stress and you
start to lose the quality oflife from those types of
symptoms that can increase whatwe see in the pelvic floor Spasm
of the muscles or an inabilityto relax because the brain talks
(23:52):
to the pelvic floor.
You have to coordinate thesetwo.
Just as much as I'm moving myhands right now, these are
skeletal muscles.
I'm coordinating them in avoluntary but very involuntary
manner.
I'm not thinking about it.
I have no idea what musclesthese are anymore.
I forgot that a long time agofrom basic anatomy.
But the muscles that I'mwiggling in front of all of you
right now are identical to themuscles in my pelvic floor the
(24:15):
puberectalis and external analsphincter that I learned when I
was potty training to open, upand close, and these muscles, if
I have these types of stressors, may not want to open anymore
and that leads to an increasedburden of stress, which leads to
more tightening of the pelvicfloor muscles, which leads to
increasing stress you can seewhere I'm going with this and
(24:35):
becomes a cycle and I call itbreak the cycle.
But here's where Kate comes intoour pyramid here, which is when
you have all that constipationand you feel horrible, you don't
want to eat and you may developsymptoms like our federal.
Eat less and so, because youeat less, you lose weight and as
you lose weight your GI tractslows down and you lose motility
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, which means when you eat youfeel even worse.
So you eat even less and thenyou lose even more weight and
then you get to worse.
So you eat even less and thenyou lose even more weight and
then you get to a point whereyou don't have enough muscle
mass to impact or to work themuscles in the pelvic floor.
I see lots of patients who comein and they say I know my
problem is my pelvic floor andI've been to physical therapy,
but my physical therapist can'tfix this.
(25:19):
And I'll tell you in myacademic program if your BMI is
less than 16, my physicaltherapist won't touch you
because there's not enoughmuscle down there to fix.
So this becomes a cyclicspiraling process and the
problem I think that we fallinto is we don't understand how
to explain this to patients,because we go directly to the
weight and it's critical and wehave to fix that.
(25:40):
But here's what patients hear,no matter what you say, and it's
critical and we have to fixthat.
But here's what patients hear,no matter what you say.
You think I have an eatingdisorder.
No, I don't.
What I'm saying is that weightrestoration is key and you fall
into this process of low weight,inability to eat, pelvic floor
doesn't work.
Stress making this all worse.
And, from my standpoint, whenwe're looking at a cyclic
process, I don't want to breakthe cycle at just one point.
(26:04):
I want to blow up that cycleand I think the best way to do
that is to engage all of usphysician practitioners,
behavioral therapists,psychologists and dietary
experts because that's reallythe only way we're going to get
them better.
So I like to say, can stressplay a role?
At the beginning, yes, I thinkmore so an irritable bowel and
(26:24):
pelvic floor.
But over time, constipation canlead to more stress, which
leads down this pathway of doom,as I like to call it.
But we can fix this problem.
Dr. Megan Riehl (26:33):
We can bust that cycle.
Kate Scarlata (26:36):
I think the notion of restricting food.
Patients don't realize thatthat impacts the motility and is
going to bring them down.
Like your efforts are goingbackwards, you know you're not
going in the right direction.
That whole motility effect it'sa muscle, it needs nutrients
and fuel and that message hasn'tgotten out to them strong
(26:59):
enough.
I don't think and I'mconstantly saying this to
patients you need the energy foryour body to work.
It's just so important.
Darren Brenner, MD (27:08):
Even there, when we talk to practitioners to
put this in a little bit moretechnical terms, I tell my
patients even if you can justeat a little bit, try and graze
throughout the day, it's thegastrocolic reflex.
Patients go to the bathroom, orI should say patients,
individuals go to the bathroomfirst thing in the morning and
after meals.
When people come in they say Ieat and I poop, that's
completely normal because it'sthat reflex.
(27:29):
That's that increase for thepractitioners of high amplitude
propagative contractions.
And then we have medicationsthat we use that activate GCC
receptors, the secretogogslinacletide, placanetide.
These are activating the samemechanisms that food does to
help us go to the bathroom.
So at the end of the day,having a bowel movement, food is
key and essential.
Kate Scarlata (27:49):
Absolutely Good point.
Dr. Megan Riehl (27:51):
And the dream team approach of incorporating
several differentmultidisciplinary specialists is
so critical here because it isanxiety-provoking when you've
gotten into the cycle and that'swhere you know, in addition to
your treatment as the physician,Kate's treatment as the
dietician, my treatment as thepsychologist we're going to
(28:13):
utilize cognitive behavioraltherapies that are specific to
those GI concerns that you have,the avoidant behaviors, the
fear of reintroducing food.
So there are treatment optionsout there to certainly break
these cycles.
It's just a matter of gettinginto the hands of that right
team.
And so if you haven't foundthat and Dr Brenner is
(28:34):
explaining the cycle and you'relistening and just nodding your
head, going yes, yes, yes, yes,that's me Keep reaching out for
those strategies and even in ourbook we give you a ton of
resources to help create yourown dream team.
Darren Brenner, MD (28:49):
Yeah, Megan, if I may.
I'm sorry.
If I can add one more point, Iapologize, just for the
practitioners and the patientsalike.
If you have this type ofconstipation, please, from the
practitioner standpoint, behonest with your patients.
Tell your patients you can'tfix this alone.
Patients don't expect thepractitioner to be able to fix
this problem with medicine.
It doesn't work.
So we have to be realistic inthis process.
Dr. Megan Riehl (29:10):
Yeah, we have to all work together for the
sake of the patient's well-being.
Kate Scarlata (29:17):
IBS-C, or irritable bowel syndrome with
constipation, is a commoncondition in which people
experience constipation, alongwith other belly.
Symptoms like pain, bloatingand discomfort Sound familiar.
Many people with IBS-C arewilling to give up key parts of
their lives in exchange forsymptom relief.
(29:38):
And because the causes of IBS-Cmay differ for each person,
there is no one-size-fits-alltreatment approach.
If you're suffering from IBS-C,you may have to try a number of
different medications beforeyou find the right one for you.
So don't be okay with justfeeling okay.
If you have IBS symptoms thatcontinue to bother, you, talk to
(30:01):
your healthcare provider tofind out if your current
medication is right for you orif it's time to try something
different.
The more you know about IBS-C,the better prepared you will be
to speak with your doctor aboutthe right treatment option for
you.
Dr. Megan Riehl (30:18):
And as we shift to some other kind of potential
factors when it comes toconstipation, can you talk a
little bit about intestinalmethanogen overgrowth and its
potential relationship toconstipation?
What is it, how do we test it,how do we treat it?
Darren Brenner, MD (30:33):
What is it?
That's hard to define.
I think we're in the fledglingstages of understanding these
things and truly understandingour microbiomes.
People come in every day.
They're like, like I saidearlier, can I just take a
probiotic, fix my microbiome?
I do personally think that thegut microbiome is the gatekeeper
to everything, not just GI,allergy, immunology, pulmonary
(30:56):
issues, rheumatologic issues.
But the reality of thesituation is I'm going to
minimize, and I don't mean to.
It's not as simplistic as thehuman genome where we can map it
.
The gut microbiome is differentfor everybody and it changes
with very simple perturbations,like I said, just as simple as
changing our diet.
So I think we are really in thefledgling stages, we're at the
(31:17):
base of the iceberg andunderstanding it.
So I don't think we know itwell enough to manipulate it.
But one thing that has beenelucidated is this idea of emo,
and I'm glad you bring this up,megan, because I think everybody
just lumps this in to the SIBOcategory, and it's not.
It's something completelydifferent, which is why the
acronym has changed.
Remember, ladies and gentlemen,sibo is small intestinal
(31:42):
bacterial overgrowth.
Now I stress the small and thebacterial, because when we go to
emo, those disappear.
Emo is intestinal.
Ie.
It may not be in your smallintestine, it may be in your
colon.
Methanogenic these are notbacteria.
They are archaea or primitivesingle-celled organisms that
(32:04):
overgrow, and so you can findthese things in the GI tract.
And they are methanogens,meaning that they produce
methane, and methane has beenshown in clinical trials to slow
gut motility.
So I think about these as apotential trigger for slow
transit constipation.
But they're also associatedwith some of the abdominal
(32:25):
symptoms you experience, likethe bloating and the distension,
and in many cases they aretreated differently than SIBO.
So people come and they sayI've been treated for SIBO and
SIBO, and SIBO and SIBO and it'snot doing anything.
And it may be because it is not, again, small bacteria but
intestinal methanogens.
Now the best way to test forthese right now is with breast
(32:46):
tests, and you can use glucoseand lactulose breast tests, and
these are done in some clinicalpractice or academic center labs
, but there are multipleproprietary institutions out
there that you can get this kitand do it at home while you're
watching TV on your couch.
The accuracy of these tests,from my standpoint, still has
yet to be elucidated, so I dolike to tell everybody if you
(33:09):
get a positive test for SIBO oremo.
Don't put all of your eggs intothis basket.
Like I said before with theVenn diagram, do not focus
solely on this.
This may not be the onlyproblem or even the problem that
is causing your symptom profileand I mention that because I
come to a lot.
I see a lot of patients whocome in.
They're like I haveconstipation because I have
(33:30):
intestinal methanogenicovergrowth, and then I do a
couple of different tests and Isay you may have intestinal
methanogenic overgrowth and emo,but there are a few other
things going on that we have tofocus on as well.
Kate Scarlata (33:41):
That's right, like, is it the chicken or the
egg?
You know, like, what's causingthis emo, a motility or
something else, right?
Darren Brenner, MD (33:50):
Right.
Where is it matters?
Because when we think abouttreating and we treat primarily
with antibiotics there's someherbal therapies that have some
data, some studies we didrecently in Northwestern for an
herbal called the Atrantil, butthe therapeutics and what you're
going to be able to use toimpact emo is probably going to
(34:11):
be shown to be quite differentthan what we use for SIBO.
Kate Scarlata (34:11):
Can you just talk a little bit about Atrantil
, because I get a lot ofquestions about that.
In your study, did it reducemethane?
I know there was a reduction inbloating, right, but did it
reduce the actual methane levelsas well?
Darren Brenner, MD (34:24):
Yeah, it's a really good question because
that's what we're looking at.
We're looking at symptoms andcorrelations to methane
responses in two differentfashions.
One was did it just absolutelyreduce methane?
And two was did it lower itbelow the threshold of normalcy,
ie 10 parts per million?
Now I will say truth inadvertising.
This is a small study.
(34:45):
It's an open-label study.
It had to be done in one yearand it was done during COVID and
so every patient who got atransult knew that they were
getting a transult.
So it wasn't compared toplacebo.
But I'm fine with that becauseI call this a case-based,
real-world analysis of this typeof therapeutic and that's what
people are doing with probioticsevery day.
(35:05):
We use the NIH PROMIS scales asour threshold to determine who
responded, and we wanted to,because if we're truly treating
intestinal methanogenicovergrowth or emo, we don't
expect it to improve some of theother PROMIS items like reflux
or dysphagia.
And it didn't like reflux ordysphagia and it didn't.
(35:26):
What the patients responded towas we saw significant
improvements in bloating andabdominal distension and
discomfort and a very closetrend.
It didn't meet statisticalsignificance but it was close
for constipation the cardinalsymptoms of emo.
We also looked at adequaterelief.
We know this is a validatedendpoint.
The vast majority of ourpatients had irritable bowel
syndrome, were positive formethane and more than 50% of
(35:47):
patients endorsed adequaterelief at the end of a month of
treatment compared to how theywere at baseline.
The next thing is the safetyprofile.
We had really no serious severeadverse events whatsoever.
The interesting part was we sawreally no changes in methane no
absolute changes over time, andcertainly there were only about
three or four patients thatdropped below the 10 part per
(36:08):
million threshold.
Now, the vast majority ofpatients that we enrolled
weren't very high above thatthreshold.
The price per million was inthe probably 10 to 20 range, so
there could have been a flooreffect.
But it also begs the questionwith this therapeutic, which
does contain some barkPeppermint oil.
I think many of ourpractitioners and listeners are
familiar with what peppermintoil can do.
(36:28):
So some things we don't know alot about, some things we do,
but very natural interventionsthese are the things that we're
trying in these patients.
Awesome.
Dr. Megan Riehl (36:36):
All right.
So you mentioned this.
You're starting to talk alittle bit more about the
potential things that patientscan try to help with their
constipation, and one thing thatwe frequently hear is fiber.
So do you have a go-to fibersupplement as a
gastroenterologist that you feelcomfortable recommending to
your patients, or do you justsend the patients to one of your
(36:56):
fabulous dietitians and havethem help with fiber intake?
What's your approach?
Darren Brenner, MD (37:02):
So my dietitians are fabulous, but if
I sent everybody who neededfiber for constipation to them,
woe to the patients who reallyneed to see them.
So, yes, I do have a go-to andI think in GI there are two
schools of thought people whobelieve in fiber and people who
don't, at least based on studiesthat came out of the University
of Michigan, where you practice, looking at what practitioners,
(37:22):
specificallygastroenterologists, recommend
as first and second lineinterventions.
So I will give all of thesesynonyms for the one I use
Plantago ovato, isfagula in myworld.
Ground up corn husk, okay.
Psyllium soluble, minimallyfermentable, gel-forming fiber.
(37:43):
I think this is the best.
This is my go-to and this isthe one that I recommend, based
on clinical literature andclinical experience, for
patients with chronicconstipation and irritable bowel
syndrome or constipation.
Now, the vast majority of thepeople that I see do come in
with a complaint of bloating anddistention and I don't minimize
(38:03):
that even this one has thepotential to cause this.
So I always start with the old,start slow and low and titrate
from there.
I do not try to pound 20 to 30grams of fiber, as recommended
by everybody, into somebody onthe first day.
They will blow up like aballoon and want to kill you.
(38:23):
I've had this experience.
I have tried the differentfibers and supplements at DDW
and then laid on the floormiserable, because I'm not
afraid to share the fact thatfor 20 years I have suffered
from post-infectious irritablebowel syndrome.
So I am not only a patient, I'malso a client and if I use
fiber, this is the one I use.
I think it is the mosteffective with the least
(38:44):
likelihood to give gas andbloating.
And again, I start very slow, acouple tablespoons a day with
meals and I work my way up fromthere.
Dr. Megan Riehl (38:51):
Perfect.
So take heed, so that you tooare not on the floor low and
slow and work your way up to theproper daily dose.
And then when do you escalatefrom some of these?
Because that's over-the-counter, right, we can get
over-the-counter supplements andmedications when do you
escalate to something like someof the prescriptions you've
(39:14):
mentioned earlier?
Darren Brenner, MD (39:15):
Yeah, you know I'm a big fan of
over-the-counters.
When we published oursystematic review a couple years
ago on all the over-the-countertherapies, I'm a big fan of PEG
3350.
Everybody starts there.
So if they don't want fiber orthey fail fiber, everybody
starts there.
Now when I say I'll fail fiber,I'm also talking about Kate's
dietetic interventions.
So I talk about kiwis, mangoes,prunes, with everybody that
(39:36):
walks in the door.
I know our dieticians are bigfans of chia seeds as well.
So I do like people to gohealthy and natural first.
When people fail PEG, that'swhen, in many cases, I will
start thinking about theprescription therapeutics.
That does not mean that I'manti-Sena or bisacodyl.
I use these more as rescues.
I'm not adverse to magnesium.
(39:58):
A lot of my patients havealready come in and failed
magnesium because it's a naturalsupplement and they've tried it
.
But where I really start todifferentiate is with the
severity of the abdominalsymptoms the pain, the bloating,
the discomfort.
Prevention none of theover-the-counter therapies have
ever been shown to improveabdominal symptoms and in fact
(40:29):
in the clinical trials some havebeen shown to worsen them.
So when somebody walks in thedoor and says my predominant
symptom is pain, discomfort andbloating, yeah, I can get my
bowels under better control, thefrequency, texture, straining
and complete evacuation with theover-the-counter.
That's when I go to theprescriptions, because the data
is much more robust for helpingthose abdominal symptoms.
Kate Scarlata (40:44):
Awesome.
I don't want to get totallyinto brands, but is there one
that's more?
First line.
Darren Brenner, MD (40:51):
Yeah, for the prescriptions, Kate, it
comes down to my four Cs, butI'll focus on the first two,
which are cost and coverage.
In many cases, unfortunately,in 2024, and I think all of us
practitioners hate this what weprescribed is dictated by what
insurance gets as their initialtiers, and that's what we have
to give these individuals, andthe differences can be hundreds,
if thousands, of dollars, andso we're a little bit restricted
(41:13):
in that process.
So, realistically, that's mygo-to.
Kate Scarlata (41:17):
Yep, that makes a lot of sense.
I know I just switchedinsurance so I'm hearing you.
It's like a whole new world.
I'm trying to figure out what'scovered and what isn't.
I don't think I'm going to letgo of the milk dud analogy
earlier.
I keep thinking that was one ofmy favorite candies growing up.
So, yes, if you areexperiencing poops that look
(41:40):
like milk duds and you haveconstipation, as Dr.
Brenner has explained verybeautifully, there are some diet
and lifestyle interventionsthat I often will use with my
patients, so in individuals thatI consult with.
So I'm just going to brieflyrun through some of these as a
review.
Green kiwi fruit is my go-to andI tell people to buy it in bulk
(42:03):
.
Wash it, chop it up, keep it inyour freezer.
It's a great.
You can just throw it into asmoothie.
It's two green kiwi fruit thathave the best sort of efficacy.
You can keep the skin on in asmoothie.
You're not even going to see itor taste it and it's fine.
It's extra fiber for you.
Mango has excess fructose, whichis very osmotic.
So Dr.
(42:24):
Brenner mentioned thatSorbitol-containing foods like
prunes or apricots peaches thosealso have a lot of osmotic
effects, pulling water into thegut, that may soften up your
stool.
I am also a huge psyllium huskfan so I add it to my smoothie
and I just go titrate slow.
I get Kate Farms (note (42:44):
should be Kate Naturals).
It's a powdered psyllium huskand about a teaspoon is four
grams of fiber.
I think that's a great startingpoint for most people and then
you can titrate that up to kindof see where you are.
But, as Dr.
Brenner mentioned, it's soluble, which tends to be a more
tolerable type of fiber.
It's not adding a lot of bulkto the stool.
We already have a lot of bulkto pass.
(43:05):
It's low fermentable, which isgreat, and then that viscous
property is great because itsops up extra fluid softening
stool.
It's low fermentable, so itstays intact in the colon to do
the job that it does.
So that is absolutely myfavorite favorite.
The other idea is a squattypotty.
If you talk to any GI dietitianthey all have them, including
(43:27):
me.
I have a streamlined one that'skind of see-through, very, very
posh.
But we talk about the properpoop position in our book on
actually page 329, so that youcan kind of see you want to
raise those knees above yourhips, open up that rectal canal
angle and let things flow alittle bit more easily into the
(43:48):
porcelain throne.
I love that.
Always make sure, as Dr.
Brenner mentioned, fiber shouldbe titrated up slowly.
Let your body adapt.
There's a big ecosystem goingon, trillions of microbes in the
colon and they're going to lovethat fiber you're upping in
your diet.
So just go slow.
Lots of fluids to have yourbody adjust.
And then exercise is anotherreally good thing.
(44:09):
So keep your body moving.
I think a good long walk a lotof people will be like, oh, come
home and be ready to hit thetoilet.
So I think that's important.
And another really importantpoint that Dr.
Brenner mentioned was eatingregularly.
So we do have that gastro colicreflex after we eat.
That stimulates colonicmotility.
So if you're skipping to avoidsymptoms, you're not going to
(44:33):
take advantage of that gastrocolic reflex.
So eating regular meals is key.
So that's my little spiel, Dr.
Riehl.
Hey, is the Squatty Potty likea real thing?
Dr. Megan Riehl (44:44):
I saw it on Shark Tank and he said you know,
yes, I endorse this thing.
(45:07):
So it was actually from Dr.
Brenner where I was able toreally, you know, remind our
patients of the value andimportance of our posture and
our behavior as well, on theporcelain throne.
So thank you, Dr.
Brenner.
A couple other words about, asyou mentioned, we go back to
that cycle that people get intoand recognizing that stress can
(45:31):
be a big factor and sometimesthe stress is completely related
to just your bathroom habits,and so if you're somebody that
does, you're afraid to go to thebathroom at work because you're
like, ah, people are going towonder what I'm doing in there
and we have Poo-Pourri now, likeso it's so important to not
(45:52):
miss your body's cues that it'stime to go, and when you do, you
start to really impact thatbrain-gut connection where the
brain is saying like, hey, wegot to go, I got signals from
down below and you're not going,so now I'm going to have more
clenching, spasming, anxiety,pain.
So it's so important that welisten to those cues.
(46:14):
And the other side of this isreally about balance that you
know if you're havingconstipation, balance in life in
general which is good for allof us, whether you have
constipation or not is so key,and so that comes in the form of
self-care and so practicingrelaxation.
And you can really up this bydoing gut-directed relaxation or
(46:37):
gut-directed hypnotherapy,which is actually an
evidence-based behavioraltherapy to help with the
management of constipation, evenif you don't have access to a
GI psychologist to guide youthrough this.
The world of digital behavioraltherapeutics is evolving, and
so there's an app that you candownload now the Nerva app.
(47:00):
That's a gut-directedhypnotherapy app that provides
you with a behavioral strategyto really address the
restoration between the brainand the gut that can become so
dysregulated with our gut healthand, you know, for a variety of
reasons, as we've hit on,whether it be our nutrition, our
stress, the mechanics of ourtoileting and our motility.
So there's lots to considerhere and finding that balance
(47:25):
through both movement andrelaxation.
You guys have all heard mealready talk about the benefits
of diaphragmatic breathing, butthat's a beautiful strategy that
can help to quickly break thatstress cycle, while you then can
employ a variety of othertechniques and strategies.
So we just want to be mindfulthat constipation is not a one
(47:49):
thing is going to fix it all alot of times, and so we hope
that our guest today, Dr.
Brenner, gave you lots toconsider and maybe ponder while
you're on that porcelain throne,but don't ponder for too long.
A lot of times, withconstipation, people are sitting
on the toilet for far too long,and maybe, Dr.
(48:10):
Brenner, how long shouldsomebody sit on the toilet
before they decide you know what, now's not the time and they
get up and go?
Darren Brenner, MD (48:16):
I usually tell people five to 10 minutes
and override your brain.
You can override, lift yourlegs and walk away, and I want
you to do that.
And a lot of times people havea lot of difficulty and, Megan,
that's where you can come in andhelp assist some of these
people.
It's getting over thatperseverative piece and
overriding that urge, knowingthat you will try again later
and hopefully have more successat that point.
Perfect.
Dr. Megan Riehl (48:37):
All right.
Well, we have learned.
I have learned so much from youtoday, and I hope our listeners
have too, and as we wrap upthis episode, we like to ask all
of our guests the followingquestion okay, what is something
that you, Dr.
Darren Brenner, prioritize whenit comes to your own overall
health and wellness?
What do you do?
Darren Brenner, MD (48:57):
That's a great question.
I will honestly andwholeheartedly admit that I
spend all day recommending toall of my patients that they eat
these very healthy, balanceddiets.
And I know the two of you havebroken bread with me in the past
and I'm probably anything, butI love my food.
I love my junk food.
There's the live to eat and eatto live, and I live to eat.
(49:18):
So I focus on the exerciseaspect.
As Kate mentioned, people tellme all the time I just can't
find the time to exercise.
Please, please, please, please,please, please, please, please,
please, please, please, please,make the time 30 minutes an
hour.
Just get up and go for a walk.
I will do my workout, if I haveto, at midnight and then go to
(49:39):
bed.
But it's amazing how much theexercise can help, just not in
the gut motility per se, as youmentioned, but also on the
psyche side and the way you feel.
I wake up every morning thenext day feeling much better if
I worked out than if I hadn't,and I think that alone can be a
major contributor overall to notonly your gut health but just
(50:00):
your health in general.
Dr. Megan Riehl (50:01):
So this man is one of the busiest.
We were lucky to grab time fromhim.
But I think it just begs tokind of show the benefit that,
even if you are living a very,very busy lifestyle,
prioritizing your own time forself-care and moving your body,
it's going to give you theendorphins, it's going to help
you be more productive in yourday-to-day work life, school
(50:25):
life, mom, dad life.
Thank you for elucidating thebenefits of that.
Kate Scarlata (50:32):
Yes, I love that I'm all about the exercise too,
but I'm going to work on.
I think we're going to have alittle nutrition consult the
next time I see you what we calla gentle diet cleanup.
Darren Brenner, MD (50:46):
Which is funny, Kate, because I'm going
to call you out here, becausethe next time you see me, we're
sharing a dinner at Fogo do Chão.
All you can eat Braziliansteakhouse.
Kate Scarlata (50:54):
I know I have to .
Really I'll have to clean up myact that evening.
That is so funny, it's true.
Oh my goodness, this wasphenomenal and so helpful on so
many levels.
You've covered everything Ithink about constipation and
more.
So thank you so much for comingon, Dr.
Brenner.
We appreciate your time,especially knowing how busy you
(51:16):
are, and keep making the GIspace a better place to work in.
Keep doing that wonderfulresearch.
It's making a difference in thelives of people living with GI
conditions.
So thank you, it is my pleasure.
Darren Brenner, MD (51:31):
Thank you for having me.
I really do appreciate it.
Dr. Megan Riehl (51:34):
Thank you for joining us as we grow this gut
health community.
We hope you enjoyed thisepisode and don't forget to
subscribe, rate and leave us acomment.
You can also follow us onsocial media at the Gut Health
Podcast, where we'd love for youto share your thoughts,
questions and experiences.
Thanks for tuning in, friends.
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